← Bulwark Takes
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- [00:00]
Richard Karn
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- [00:55]
JVL
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- [00:57]
Richard Karn
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- [00:59]
JVL
Available@pocket hose.com terms hello everyone. I'm JVL here with my bulwark colleague Jonathan Cohn and we are going to go deep and nerdy on the big beautiful bills, implications for Medicaid and people with healthcare.gov insurance and also rural hospitals. Strap in, get your nerd on. And before you do, if you want to follow this stuff, follow the channel, hit like, hit subscribe, be with us and really do hit the like button. It makes it you. You wouldn't believe how stupid the YouTube algorithm is. It really, really wants those thumbs ups. Jonathan Cohn, you had a fantastic newsletter earlier this week about the Senate version of the big beautiful bill and it's not great for Medicaid. Can I just put a quarter in the machine and let you tell people what's going on?
- [01:55]
Jonathan Cohn
Yeah, yeah, sure. No, it's not great for Medicaid, not great for the Affordable care. I mean, not great for people who need health care. The big headline about the Senate bill is that in the big picture, it's like the House bill. It's gonna take about a trillion dollars out of government healthcare programs over the next 10 years. The biggest chunk of that from Medicaid, another big chunk from the Affordable Care Act, Obamacare, if that's how you know it and you put that all together And a lot of people are going to lose health care. Probably, you know, we're looking at 11 million people projected to lose health insurance, millions more on top of that, who will have to pay more for their health care, either because their premiums are going to go up or the coverage they have is going to leave them with higher out of pocket costs. That is what the House did. There was some thought after the House passed its bill that maybe the Senate would get it. And I think a lot of us are used to this idea of the Senate being the kind of more moderating influence. Right. So if a Democratic Congress, it tends to pull, you know, pull things to the center, right. So it's a less liberal bill from the Democrats, it's going to be a less conservative bill from the Republicans. That did not really happen. If anything, it's complicated and we can get into the weeds. If anything, I would say it looks like the Senate bill is actually a bit. Takes a bit more healthcare away from people, if we want to think of it that way. Obviously, this is just. They're just putting the language out right now. The Senate has yet to debate the bill and vote on it. It could change. But if there was, you know, insofar as people were thinking, well, the Senate is going to save this bill or at least make it a lot better from the standpoint of healthcare access. No. And if anything, it's.
- [03:44]
JVL
We're getting this as. Cause it's all being scored, right? Is that like this isn't just, you know, the fake news media looking and saying, oh, 11 million people are going to lose cover, right? This is. Is this coming out cbo?
- [03:57]
Jonathan Cohn
Yeah, it is coming out of cbo. Cbo. You know, pour one out for the CBO economists who are having to work overtime. I mean, we can. This is a whole other country. Maybe we'll get into this later. That they're moving so quickly on this bill from like getting the language out to like getting it onto the floor and votes that cbo, these calculations are so complex, especially with something like this. We have a million different changes and they interact with each other and they just can't keep up. And they're trying to get these projections out as fast as they can. If you remember, we did not have when the House voted on its bill, which was a Memorial Day weekend or I can't remember now with everything Trump time. It was two weeks ago, it feels like 10 years ago. My recollection, I think was Friday or Thursday. It was literally five days after they had introduced the bill. We didn't get a final CBO score course until days later. So literally the House was voting on something for which they did not know precisely what its effects would be. And I would not be surprised if the way things are going, we end up.
- [04:57]
JVL
And that's the plan though, right? This is by design. The, the idea is to move it as quickly as possible, get it voted on as quickly as possible so that people don't know what's in it, because if they do, there will be more opposition to it. Right.
- [05:12]
Jonathan Cohn
Okay, 100%. I mean, that's very clearly what they're trying to do.
- [05:16]
JVL
To me, the most interesting part of your piece was about the secondary, like the second level implications of what this does. Because when you, when you start gutting Medicaid, it has a huge effect on rural hospitals because rural hospitals get the lion's share of their revenues from Medicaid. People on Medicaid. Can you talk a little bit what that, what that's going to mean and what, what we think the follow on effect will be for health care access for people who live in rural communities. Sure.
- [05:50]
Jonathan Cohn
So rural hospitals in general. Right. In the sort of the economic landscape of health care, rural hospitals, it's tough to be a rural hospital for all kinds of reasons that have to do with the economics of health care, the demographics. Just in general, rural hospitals struggle more than urban suburban hospitals. So there's always been a little bit more on the brink in recent years as Medicaid has expanded, which, you know, that was the whole idea of the Affordable Care act. Get Medicaid to more people, try to get closer to a universal coverage system. Rural hospitals have increasingly relied on that Medicaid money to kind of save them from oblivion. Even with the Medicaid money coming in, we've been seeing rural hospitals close. And so the danger is you take more money out of Medicaid and now rural hospitals are in bigger trouble. And here's where we get to the secondary effects because you know, when we talk about what a bill like this is going to do and we were just right, we were citing the number of people who are going to lose health insurance. And of course the immediate thing you think of, well, who are the people on Medicaid who will now not have Medicaid or people are going to have to pay more? And obviously, and that's, look, that's the most, you know, in a lot of ways the most important part of this. But there are these sort of secondary effects. So imagine you're in a earlier, you know, let's let's talk about, imagine southeastern Iowa, just because that's a place I know from actually from a previous story I was working on. And you know, there's only one hospital in one part of southeastern Iowa for 100 miles around because they've been losing these rural hospitals. So now Medicaid money, they're losing Medicaid funding as well. It's harder for them. Best case scenario, they may have to scale back, they may have to cut back on services. Worst case scenario, they have to close altogether. Now imagine you live there and you're pregnant. You're going to have to deliver a baby soon and early delivery. As we all know, that happens a lot. Hopefully good, healthy pregnancy, whatever. Worst case scenario, you're in distress, you need to get there and you're 100 miles away from a hospital. Not a hypothetical. There was some reporting, I can't remember the name of the publication. Now there's a great, it's linked in my article from a couple weeks ago about a case where somebody, it was this blinding snowstorm, they had to get to the hospital. They were okay in the end. But basically, basically there was a delivery on the side of the road by a sheriff, which was someone, you know. Later on there was a protest about sort of hospital closures there. And someone said, it's not true, we don't have maternity access in this part of southeastern Iowa. We do. It's called the sheriff on the side of the road. So you imagine that, imagine you have a heart attack and now you need to get to an emergency room. All of these things, these are ripple effects. So you may not be on Medicaid, you may be rich, you may, you know, but you still have to get to that hospital. It's 70 miles away, the blinding snowstorm. And just, you know, put yourself in that, in that frame of mind that is one of the knockoff effects. And we haven't even started to talk about jobs, economy, which is a whole other category because in most congressional districts, most states, even if you look at the top employers, I guarantee you hospitals are going to be in the top three frequently.
- [09:05]
JVL
So I want to talk about the politics of this and it starts with who gets hurt. And I think that the calculus used to be dial back 20 years ago, you thought, oh well, people on Medicaid, those are largely going to be lower income people and so probably Democratic constituents. And that is not true because we've had this big mix up and reapportionment of the voting coalitions. And so correct me if I'm wrong. Gonna be more Republicans hurt than Democrats in this.
- [09:39]
Jonathan Cohn
Yeah, yeah. So obviously we've expanded. You know, two things have happened. Medicaid expanded to cover many more people. Again by design. That was the whole point. I mean, you know, we can argue that was bad and you want to go back, but I mean, that was the debate of the Affordable Care Act. Do we expand Medicaid to cover more working people who can't get health insurance? And as a result you are seeing a lot of sort of, you know, people who were in the, not the most poor people, but people low income people, working poor people who are now getting Medicaid. A lot of them more likely to be Republicans than before. In addition to, as we were saying a minute ago, we see these sort of rural communities where there's a lot of people who are now eligible for Medicaid. If you break down the numbers, it's actually quite hard to get. Like this gets tough, like sort of breaking down who, you know which party is going to be more affected, less affected. A lot of people tried to break this down in different ways by congressional district, by state. Kff, who does a lot of this work, which is sort of the gold standard for health care research, has done some breakdowns. I spoke with a guy named Charles Gaba, who those of us who follow health policy, he's like the guru on breaking down these numbers and he did his own analysis. And if you look strictly at Medicaid, it's close. It looks like slightly, still more Democratic districts, Democratic states, but it's like pretty darn close. Getting to 50, 50. And then if you look at the cuts for the Affordable Care act, which remember a lot of people on the Affordable Care act are people just above the Medicaid line. So still dealing with working poor lower middle class, then it flips and actually it is more red states and red districts. And interestingly there's a reason for that. It's a very obvious reason for that.
- [11:17]
JVL
Because the there the big red states that didn't adopt the accept the Medicare provisions or Medicaid provisions.
- [11:23]
Jonathan Cohn
Right, exactly, exactly. So you know, Florida, Texas, I mean they got ton of people who if they had expanded Medicaid would be on Medicaid. They're not. They're getting Affordable Care act insurance, they're going to fill the brunt of those cuts.
- [11:36]
JVL
So I guess my question to you is what are the Republicans doing? Like their incentives would seem to go the other way. And it's not like the party has any fiscal hawks left in it. Like, you know, There may be three Freedom Caucus guys left who, who you know are like the Japanese soldiers on the island coming out in 1990, thinking it's still World War II, but the rest of the party is like, big budget deficits, spend everything. Who cares? And so it's a little weird. This is what I haven't quite been able to figure out. Why would they do something like this? Which is very much an old Republican move. Right. This is, this is what you'd expect from like the party of Mitt Romney and George W. Bush that was really concerned about the green eyeshade stuff. And instead they're doing this and they're going to hurt themselves. What do you, do you have any read on to what the thinking is politically here? Is it just a vestigial impulse, the party, that they haven't reconciled with who their new coalition is?
- [12:41]
Jonathan Cohn
Yeah, well, look, I mean, you speak Republican better than I do, so I actually would almost flip the question because I've been wondering these same things. I mean, I assume there's, I think, I mean, I've had conversations with some of these people, so, I mean, there's a few things going on. First, let's, you know, you know, let's stipulate that for a lot of Republicans, they may not care about the deficit that much in reality, as we see from this bill. But, you know, they don't like, you know, they think government healthcare has gotten too big. They don't want government interfering in health care. They don't like the taxes. They go to fund it. They want to free up money to pay for tax cuts. And obviously this bill does all those things. It shrinks government health care. But they can go into. Yeah, it can go. So I do think. Yeah, right. So, I mean, let's start there and let's acknowledge they're, you know, true believers. And I think there's, you know, that's where their starting point is. Certainly let's also acknowledge political incentives here. Trump wants this bill, and I don't want to, you know, that. I mean, if you're, you know, that's a big part of this, and he's put all his baskets into this. And, you know, the tax cuts in there and the rolling back, the green New Deal is in there and there's immigration pieces in there. So, you know, they don't want to be on the wrong. They don't want to be on what they think is these sort of, they don't want to be on the opposite side of Trump, but. Or on what they believe or what they're telling themselves is what MAGA will want. Now, this is where we get into the political difficulty, which is, as you mentioned, as we were just discussing, you look at who's gonna feel this bill, feel these cuts. And it's a lot of Republicans, It's a lot of base Republicans, a lot of base MAGA Republicans. I mean, go back four or five months, you may remember Steve Bannon, of all people, was on, I think it was on Fox, or maybe it was on his radio podcast. Now, I can't remember very clearly saying, you want to be careful about cutting Medicaid because that's a lot of our people. Trump's own pollster said that. I mean, Trump made a big deal about saying we are not, you know, we're not going to cut Medicaid, which, of course, like every other vow that Trump has ever made, you know, whatever. I think what's going on here, partly we talked earlier about the speed and how, you know, the idea is to sort of not let the public really focus on what's in this bill and really come to grips with it. I think there's some of that dynamic inside Congress. I think a lot of these members do not, not know what they. I mean, we've heard that from some of them. They do not know the votes. You know, it was interesting yesterday, I had a conversation. This is not on health. It was actually about a different part of this bill was on the clean energy pieces. As you know, this bill cuts a lot of the clean energy incentives. And it was from someone from a red state who was saying, you know, our, we, we've got a ton of these investments in our, in our, in our state, in our district, and if this passes, it's going to kill us. And said they were meeting with some members and their sense was one of these members hadn't really focused on it. Like, they just had not like really done the math. I mean, they had heard this might be, but they had not. And when you move a bill this quickly, when you don't have committee hearings, when you don't have time for the local press to really dig up the stories, this is what happens. I think a lot of them do not know what they are voting for. And if they know they don't, they haven't taken it on board and assimilated and really thought through what this is going to look like six months from now, a year from now, two years from now. And, you know, for House members soon enough, some of this, that it would be in time for the next Midterm.
- [16:00]
JVL
Well, this one, again, Republicans are just negotiating it themselves. It's not like they have to bring on three Democratic votes or something like that. And as I said, there is no, this is a massive budget busting bill to begin with. So, like, who cares if it's 5% worse? Do you know what I'm saying? Like, you know, if you're the Republican Party, you can have everything you want. You can do your tax cuts and pass Trump's bill and not cut Medicaid because you want to take care of your people. It just means that the deficit stuff will be a little worse. And you know what? You're already going to get killed on that as to whatever extent you're going to get killed on. So, like, why add this? That's what I don't understand. And the only thing I can think of is that there are still some old Republican members in there who just can't get their head around the idea of what their party is now. And I find that hysterical. I don't know. I mean, and here, I guess here's a last question before we get out of here. Is this the kind of thing that they will get hurt on? And what's, what's the, you, you, in your piece, you talk a little bit about the electoral history of these things. And my concern as somebody who wants to, wants to see the authoritarian project brought to a close, is that Trump will find a way to have everybody be happy with whatever, because he's very good about that in terms of managing his internal coalition. You know, he's able to keep the people who don't want forever wars happy and keep the people who want regime change in Iran happy. And that's like fraying a little bit right now, but only a little bit. Yeah. You know, will, will Republicans wind up getting hurt on this if it passes through and these cuts go through and we get to, to 2026? I mean, we'll be soon enough that people will feel that before next November.
- [17:58]
Jonathan Cohn
Yeah. So, I mean, look, we don't know for sure. Not next November.
- [18:00]
JVL
Sorry. Two Novembers from now.
- [18:02]
Jonathan Cohn
Two Novembers from now, right? Yeah. I mean, look, I, I, I, I've stopped making predictions on, you know, enough of the political universe and rules seem to have changed that. Who know, I think they're telling themselves this will not hurt. I think they are, what's the phrase, high on your own supply a little bit when they say this is all about waste and fraud and going after immigrants. And look, there are pieces of this bill that do that just they're a small piece of it. But my hunch is this will be a lot. There will be at least some repercussions we've got. I mean, at some point, reality does still matter. And if you look, let's talk about. I think so. God, I hope so. I mean, if it doesn't, we're all in a lot of trouble. And maybe I'll be the last one out there sort of saying, but wait, have you looked at, you know, have you looked at your health care bills? But in all seriousness, let's focus just on those Affordable Care act cuts alone and not even the Medicaid ones, which take a little while to kick in. And so you can see a scenario where those kind of play out later. And it's not the link between what's happening and the bill isn't quite so clear. The aca, the Obamacare changes, those kick in for next plan year. So that's 2026. Insurance companies right now are making their calculations about what they're going to charge for next year based in part on what happens in this bill. And there's a whole second debate that's related. It's not in this bill about whether to renew some extra money that's been going into the program. It's a nightmare right now for the insurance companies, by the way, filing rates with like 10 different scenarios because there's so much uncertainty. But whatever they're doing that now, those will get locked in over the summer, early fall, starting in September and October, brokers and insurers are going to start to tell people who have coverage the Affordable Care Act. They're going to start saying, this is what you're going to pay next year. Now, not everyone's going to see that notice, but a lot of people are then going to go onto healthcare.govcovered California, wherever they buy their Obamacare policies through, and they're going to then see what it costs them. And then there are going to be people who will not remember and open enrollment will end. And they're going to it's because it's shorter. That's one of the changes that's getting made and won't be able to get insurance at all. That's all going to play out starting in a period from September through January. That's a few million people at least, probably more than a few million who are going to suddenly experience sticker shock, maybe lose coverage. And we're talking big changes here. I'm not talking like, oh, my insurance cost $100 more next year. I mean, like my insurance costs $5,000 more, next year, $10,000. Or I used to have a plan that of pocket costs had co pays that were $10 or $25. Now they're $50, $100. Or I'm completely on the hook for certain things that I wasn't before. What impact does that have? I don't know. But look, we have a precedent for this. Democrats went through this when the Affordable Care act first took place. And part of what happened was prices went up. It was part of the whole process of upgrading insurance. Democrats, frankly, did not, I think, figure out exactly. There's a whole other story, what went wrong there and why that happened. And they got killed for that politically. And those memories lingered into the 2014 midterms, certainly. So I do think that people will see that and they will be angry. They'll be looking for someone to blame. I do think for Democrats, for activists, a really important part of this is making sure people know now what is at stake, what would happen. And then if this bill does pass in some form, those rate hikes do come, make sure they know why and say, you know, who's to blame for that? And, you know, they got to win that argument, obviously. But I do think, you know, at least I don't know what you're feeling. My general feeling is when a debate is confusing and there's bad things happening, people revert to their defaults. Now we're in a period, obviously there's a lot of loyal Trump voters who are never going to think Trump did anything wrong. But in general, in the same way, I think Democrats tend to suffer when there's a complex debate about immigration or crime. People think, yeah, those Democrats, they're too easy on immigrants. Those Democrats, they're too soft on crime. Well, when it comes to health care, that's like home field, right? I mean, that is. Who do people trust? They trust Democrats to protect their health care. And when their health care is going away, someone's taking away their instinct, right or wrong, whatever, is going to be to blame the Republicans. So that does feel like an argument Democrats could win if it gets to that, if this gets that far, maybe.
- [22:29]
JVL
I don't know. I mean, my default assumption on these things is that if you are a farmer in southeast Iowa and you are suddenly paying $5,000 or more for your healthcare.gov insurance and the hospital that was 40 miles away from you closes and now you drive 70 miles, you might want to blame Trump. But also at the same time, Donald Trump was mean to a trans kid in San Francisco once. And so you look at that and go, well, you know, Orlean, you know, we're coming out even, maybe even a little ahead. I. I gotta tell you, Jonathan, you are a good person. I think that one of the great things about life is people having the dignity to experience the consequences of their choices. And so I'm excited for the people who voted for Donald Trump to get to have that, because it's paternalism to protect people from the consequences. And I think this is going to be great. I'm very excited. I hope the bill passes, and I hope everybody gets what they voted for.
- [23:31]
Jonathan Cohn
I will just say, you know, as a policy person, you know, I don't, you know, who knows, you know, what'll happen? It will be if this happens. And by the way, people, you know, I always remind people, don't assume this thing's gonna pass. People forget the. The reason John McCain's thumbs down was so dramatic was that three hours before, most people thought that bill was gonna pass. And so, you know, things change, but a lot of people are gonna get hurt if this, if this passes. And I know that's, that's, that's, that's. You're not denying that. And, you know, we'll see what happens on the politics. I just don't know. I just don't know. I guess I still have enough. Like I said, I'm still. We'll run this tape in a year or a year and a half maybe, and we'll see. But I still think reality intrudes enough to shake politics up. But, you know, who knows? Maybe, you know, who knows what else is going to be going on?
- [24:31]
JVL
Stay tuned. We're going to be doing more stuff. Follow the channel again. If you didn't do it already, do me a solid. Hit the like button. We'll catch you soon. Good luck, America.